Blood Administration Lisa Randall, RN, MSN, ACNS-BC RNSG 2432.

Blood AdministrationLisa Randall, RN, MSN, ACNS-BCRNSG 2432

Types of Blood Components

• CURRENTLY USED• Packed RBC’s

• Frozen RBC’s

• Platelets

• Fresh Frozen Plasma

• Albumin

• Cryoprecipitates & commercial concentrates

• NO LONGER USED• Whole blood except

• Exchange transfusions

• Massive blood loss

Current Blood Preparation

• Leukocyte reduction prior to storage

• More effective than previous washing process

• Packed RBC’s are removed from plasma

• Removal of most WBC’s and Plasma reduces the risk of reactions/infection

• Drawback – bacterial growth if contaminated during collection/processing

Packed Red Cells (PRBC’s)

• Used to treat anemia and replace blood volume (Additional NS used for volume)

• Usually ordered when Hgb 9 and Hct 27• For asymptomatic elderly <7g/dl • Epoetin alfa (Procrit & Epogen) - increase hemoglobin

levels & reduce the need for blood transfusion• **1 unit of PRBC’s will increase the Hgb by 1

and the Hct by 3

• Usually contains 250 ml.

• Usually not use a leukocyte filter

Blood components cont.

• Platelets • To control or prevent

bleeding in platelet deficiencies -thrombocytopenia

• To treat platelet dysfunction

• Given when <20,000

• Risks• Not a substitute for

plasma or clotting factors

• May form antibodies

• Hypersensitivity reaction

Platelets• One unit contains 30-60 ml platelet concentration

• Expected increase is 10,000 per unit

• Outcome: measured by platelet counts at 1 hour and 18-24 hours post transfusion

Blood components cont.

• Albumin• To expand blood

volume or replace protein

• Used to treat shock from trauma, infection and in surgery

• Risks• Vascular overload

• Hypersensitivity reaction

Albumin

• As a volume expander…• Used for patients 3rd spacing and are hypovolemic, liver

patients

• Hyperosmolar solution acts by moving water from extravascular to intravascular space

• Outcome: adequate blood pressure and volume

• Plasma• Contains clotting

factors & protein• No platelets• Used for clotting

problems as: • DIC • Liver patients• Urgent warfarin reversal

• Risks• Vascular overload• Hypersensitivity

reaction• Hemolytic reactions

contains antibodies

Fresh Frozen Plasma (FFP)

Fresh Frozen Plasma (FFP)

• One unit = 200-250 mls

• Outcomes: improved coagulation, PT,INR, and aPTT

Blood components –cont.

• Prothrombin Complex – Prothrombin, Factors VII, IX, X, and part of XI• Used to treat clients with specific clotting factor deficiencies

• Cryoprecipitate – Clotting Factors VIII, XIII, von Willebrand’s factor, & fibrinogen from plasma

• Used to treat clients with specific clotting factor deficiencies

• May cause ABO incompatibilities

RBC & Plasma Transfusions

RBC’s - Type and cross match with potential donor blood to check minor antigens on cellsUsually 2 orders:

TypeAdminister

Blood Type (ABO & Rh)

% of General Population

O, + 35%

O, - * 7 %

A, + 35%

A, - 7 %

B, + 8%

B, - 2 %

AB, + ~ 4%

AB, - 2%

Initiation of Transfusion

• Check MD’s order & Obtain permit

• ID patient, draw blood for T+C in red top tube, place blood band and label tube.

• Start 18-20 gauge IV.

Initiation Cont.

• 2 people check unit of blood or component with laboratory slip, patient’s chart & hospital forms should include:

• Patient’s name, Medical Record #, blood band number, Unit #

• Blood component, Group & Rh factor, donor number

• Expiration date

• Compare all labels & forms of ID second time

• Check vital signs and record• 0.9% Sodium Chloride (NS) only!!!• Prime Y-type blood tubing with NS• Invert unit to mix cells• Spike blood bag, clamp off NS• Cover blood filter with blood

• Use appropriate filters

For intraoperatively For intraoperatively salvaged washed blood.salvaged washed blood.

Reduces leukocytesReduces leukocytes

Decreases fat globules Decreases fat globules

Reduces microaggregatesReduces microaggregates

Use blood administration set no more than 4 hours – each infusion must be completed in 4 hours

• Check facility policy re: # units per administration set • No more than 1 or 2 units per tubing

• Use IV pump

Important Points

• Drip rate no higher than 2 ml per minute X 15 minutes (30 ml per 15 minutes or 120 ml/hr.)

• Seton etc. set pump at 75 to 80 ml/hr. for 15 min.

• Remain with pt for first 15 minutes or first 50 ml

Important Points

• Vital signs prior to administration & in 15 min. X 4, • then q 30 minutes, until transfusion complete--then X 2

• No meds or fluid other than NS to be given in line with blood!!!

• CHECK POLICY AND PROCEDURE of facility!!

• Infuse over period specified (2-4 hours)

• Blood cannot be out of refrigerator more than 30 minutes prior to administration –PLAN AHEAD!!

• BE READY TO START BEFORE GETTING BLOOD!!

Important Points

Transfusion Reactions

• Anaphylactic

• Allergic or Hypersensitivity

• Hemolytic

• Febrile


• Transfusion-Related Acute Lung Injury

• Massive Blood Transfusion Reaction

• Sepsis

• Circulatory Overload


• Incompatibility between donor and recipient's blood

• What changes in vital signs would you expect to see?• Consider a temperature increase of 2 degrees significant• What drugs are commonly given prior to transfusion?

Prophylaxis/preadministration

• History of an allergic reaction to a previous blood transfusion:

acetaminophen (Tylenol)

diphenhydramine (Benadryl)

• High risk of fluid overload:

furosemide (Lasix) or another diuretic

Allergic Reactions - 1%can occur during or after

transfusion

• Mild• Urticaria • Itching• Flushing

• Severe– Wheezing– Dyspnea– Bronchospasm

Obtain order for antihistamine and antipyretic if pt. has temp elevation•If pt. responds to these, may have order to resume transfusion

Anaphylactic Reactions

• Can occur very quickly, with only a small amount of transfusion – usually within 50 mls

• Hypotension, SOB, Tachycardia, Shock• Loss of consciousness• Facial or laryngeal edema• Dizziness, Chest tightness, abdominal cramping

• Get order for epinephrine & corticosteroids

Hemolytic Reactions - 0.004% or 1:25,000

ABO incompatibility

RBC’s clump &

block capillaries decreasing blood flow to organs.

Hgb released, blocks renal tubules – can cause renal failure.

Potassium released.

Hemolytic Reactions

Key Indicators:• Apprehension Fever/chills• Headache Burning at IV site• Chest pain Low back pain• Tachycardia Hypotension• Urticaria • N/V

• Acute-usually occurs after 50 ml. infused Lemone – after 100 to 200 ml infused

3 or 5-10 days up to several months later

Pyrogenic: (non-hemolytic)

Febrile or Bacterial

Occurs within first 15 minutes • Sensations of Cold

• Fever

• Chills

• Hypotension

• Shock

Reaction to donors WBC’s, plasma proteins, or contamination

Transfusion-Related Acute Lung Injury

• Reaction between recipient’s leukocytes & donors antileukocyte antibodies due to sensitization by pregnancy or previous transfusions

• Pulmonary capillaries inflamed • Fluid in alveoli • Respiratory distress• Risk greatly reduced with leukocyte removal and washed

packed cells

Massive Blood Transfusion Reaction

• Replacement exceeds usual blood volume• Drop in clotting factors, albumin, & platelets

• Hypothermia

• Citrate toxicity & hypocalcemia – Pedi pt.• 10 ml 10% calcium gluconate / liter of blood

• Hyperkalemia

Graft vs. Host

• Stem cells in blood products invade marrow of immunodeficient pt.and grow as a foreign tissue which is rejected

• Lymphocytes in blood products attack immunodeficient pt.

• 7 to 30 days after transfusion

• Skin, GI tract, & liver damage

Nursing actions if reaction occurs

• Stop transfusion immediately

• Continue N/S IV with new tubing

• Provide appropriate care for client

• Notify physician of clients signs and symptoms

• Follow facility policy and send bag and tubing to lab

• Obtain blood and urine specimen for free hemoglobin test

Charting

• Document the following:

• Time of the transfusion reaction

• Type and amount of infused blood or blood product

• Clinical signs of the transfusion reaction in order of occurrence

• Vital signs

• Specimens sent to the lab

• Treatments given and patient’s response to treatment.

• If required by your facility policy, complete the transfusion reaction form and any quality variance forms.

Major/Urgent Surgeries Performed in the Inpatient Setting

• Ablative procedures:• Amputations

• Colostomy

• Reconstructive:• Total joint replacement

• Heart bypass surgery

• Palliative• Colostomy for CA

• C-sections

Major Surgeries Performed in the Inpatient Setting

Emergency Surgery

• Transplants

• Ruptured aneurysm

• Life-threatening trauma

Critical Thinking Exercise

The pt.’s blood type report indicates that he is Type A+. The unit of PRBC's that the bank has provided is labeled as Type O negative.

Can this patient safely receive this blood?

Why or Why not?

Critical Thinking Exercise #2

The pt.’s Type & Crossmatch report indicates that he is Type A-. The unit of PRBC’s that the bank has provided is labeled as Type O+.


Why or Why not?

Critical Thinking Exercise #2The pt. is Type A-. The unit of whole blood is labeled as Type

O+.


1. Universal donor in emergency

2. Type O has A & B antibodies but no A or B antigens

3. Rh+ D antigen to a Rh- patient1. male vs. female?

2. Age of female?

3. Level of emergency situation?

Rh – mother

with

Rh + baby

What med is used?

Drug used: RHo (D) Immune Globulin (RhoGAM)


The patient is a Jehovah’s Witness. What factors impact care for bleeding in an emergency situation?

Compare this situation to the patient who is concerned about the safety of blood component transfusions?


The patient is scheduled for an elective procedure such as a total knee replacement.

What measures can be taken to decrease the risk of transfusion reaction?

What type of reaction might still be possible?

Autologous transfusion

What are the benefits of Autologous transfusion?

Blood you receive should definitely match yours. Risk of getting any allergic reaction will be very low. Blood will be available if you have a rare blood type. No infectious diseases - hepatitis, syphilis, AIDS, etc. Safe and well-tested procedure.


Who can have Autologous transfusion?

Patients less than 65 years old.

Patients without serious medical conditions like serious heart and lung diseases.

Patient’s with hemoglobin level of at least 11g / dl before each donation

A "cell-saver" technology collects blood as it is lost during surgery, cleanses it, and places it back in the patient's body, all in a continuous loop.


Directed donation of blood

Sticker "Directed Donation" affixed directly on the unit.

Note: Directed donations units may also be collected by facilities other than yours.

A complete check of the unit identification compared to the patient identification is performed on each unit to ensure unit is given to the correct patient.

Every unit of blood is tested forEvery unit of blood is tested for

HIV-1 and HIV-2 (AIDS)HBVHBsAgHCVHTLV-I/II Human T-Lymphotropic Virus (HTLV-I and HTLV-II)

ABO and Rh factor & cross match if RBC’ssyphilis elevated ALT

The presence of unexpected antibodies that may cause reactions after the transfusion

CMV, a test for the cytomegalovirus (performed on physician request) * OK if WBC’s filtered out

NAT (Nucleic Acid Testing) - a new technology that can detect the genetic material of Hepatitis C and HIV to identify these viruses faster and more accurately

100% of the blood products in USA are filtered to remove 100% of the blood products in USA are filtered to remove leukocytes that can harbor viruses and infections.leukocytes that can harbor viruses and infections.

THE END!

Blood Administration Lisa Randall, RN, MSN, ACNS-BC RNSG 2432.

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